Citation Nr: 21023093 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 17-37 244 DATE: April 20, 2021 ORDER As new and material evidence has been submitted to reopen a claim of entitlement to service connection for gastroesophageal reflux disease (GERD), the petition to reopen the claim is granted. Entitlement to service connection for GERD as secondary to the service-connected adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder is granted. Entitlement to service connection for obstructive sleep apnea as secondary to service-connected adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder is granted. Entitlement to an increased rating for an adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder, rated as 30 percent disabling prior to July 10, 2016 and 50 percent thereafter, is denied. REMANDED Entitlement to a rating in excess of 10 percent for patellofemoral syndrome, right knee is remanded. FINDINGS OF FACT 1. By a rating action in June 2012, the Regional Office (RO) denied the Veteran's claim of entitlement to service connection for GERD. The Veteran did not perfect an appeal of that decision, and the decision became final. 2. Evidence received since the June 2012 rating decision relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for GERD. 3. The evidence is at least in equipoise as to whether the Veteran has GERD that was either caused or aggravated by his service-connected adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder. 4. The evidence is in relative equipoise as to whether the Veteran's obstructive sleep apnea was either caused or aggravated by his service-connected adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder. 5. For the appeal period prior to July 10, 2016, the Veteran’s adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder was manifested by no more than occupational and social impairment with occasional decreases in work efficiency and intermitted periods of inability to perform occupational tasks due to such symptoms as depressed mood, anxiety, and chronic sleep impairment without occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas or total social and occupational impairment. 6. For the appeal period beginning on July 10, 2016, the Veteran's adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder was productive of, at most, occupational and social impairment with reduced reliability and productivity without occupational and social impairment with deficiencies in most areas or total social and occupational impairment. CONCLUSIONS OF LAW 1. The June 2012 rating decision that denied the claim of entitlement to service connection for GERD is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 2. The criteria for reopening the claim of entitlement to service connection for GERD have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for GERD as secondary to the service-connected adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for obstructive sleep apnea as secondary to the adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for a higher rating for adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder, rated as 30 percent disabling prior to July 10, 2016 and in excess of 50 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.126, 4.104, Diagnostic Code 9440. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2006 to January 2010. These matters come before the Board of Veterans' Appeals (hereinafter Board) on appeal from rating decisions of the Regional Office (RO) in Indianapolis, Indiana. By a rating action in October 2014, the RO denied the Veteran’s attempt to reopen his claim of entitlement to service connection for GERD; that rating action also denied the claim for a rating in excess of 10 percent for right knee patellofemoral pain syndrome. Subsequently, in a rating action in September 2015, the RO increased the rating for adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder from 10 percent to 30 percent, effective June 25, 2015. Thereafter, in March 2016, the RO denied service connection for sleep apnea. The Veteran perfected a timely appeal to those decisions. In December 2020, the Veteran testified before the undersigned Veterans Law Judge during a virtual hearing. A copy of the transcript is of record. Following the hearing, the record was held open for 30 days to allow for the submission of additional evidence. Additional evidence, namely etiology opinions from N.A., have been received since the hearing. The Board notes that, in October 2018, the Veteran was notified of the denial of his claim of entitlement to an increased rating for patellofemoral syndrome of the left knee in a rating action on September 28, 2018. In December 2018, VA received a notice of disagreement (NOD) with the denial of the claim for an increased rating for the left knee disorder. A statement of the case (SOC) in response to the timely NOD was issued in January 2019. To date, a substantive appeal has not been received; accordingly, that issue is not currently before the Board. Service Connection Generally, a claim that has been finally denied in an unappealed RO decision or a Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception is that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C.§ 5108. New evidence means evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Pursuant to Shade, evidence is considered new if it has not been previously submitted to agency decision makers, and it is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The Court of Appeals for Veterans Claims (Court) interprets the language of 38 C.F.R. § 3.156(a) as creating a low threshold and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112, 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id. see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for GERD, secondary to adjustment disorder The Veteran's claim for service connection for GERD was denied by a June 2012 rating decision. The evidence considered at the time of the June 2012 rating decision included the Veteran’s service treatment records which were negative for any complaints of or treatment for a gastrointestinal disorder, including GERD. The record also included report of a VA general medical examination dated in October 2009, which was negative for any complaints of or treatment for a gastrointestinal disorder, including GERD. By a rating action in June 2012, the RO denied the Veteran's claim of entitlement to service connection for GERD based on a finding that the evidence failed to show that the condition was incurred in or caused by service. The Veteran did not file a notice of disagreement (NOD) with that determination within one year of the notification thereof in June 2012. However, no further communication regarding the Veteran’s claim of entitlement to service connection for GERD was received until June 2014, when VA received his petition to reopen such claim. Therefore, the June 2014 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Moreover, no additional evidence was received within the one-year appeal period, and no additional service records (warranting reconsideration of the claim) have been received at any time. See 38 C.F.R. § 3.156(b), (c). The Veteran's petition to reopen his claim of service connection for GERD (VA Form 21-526) was received in June 2014. Evidence submitted since the June 2012 rating decision includes updated VA treatment notes, a March 2016 VA examination report and a January 2021 private opinion. Submitted in support of the claim were VA progress notes dated from December 2010 to December 2015, which show that the Veteran received clinical attention for symptoms of a gastrointestinal condition, diagnosed as GERD. Specifically, during a clinical visit in February 2013, the Veteran complained of increasing discomfort with “heartburn and reflux. The provider stated that he encouraged the Veteran to abstain from alcohol as it will make his GERD and obstructive sleep apnea worse. A primary care note dated in December 2015 reflects an assessment of GERD. The Veteran was afforded a VA examination in March 2016. Following a physical examination, the examiner reported a diagnosis of GERD. The examiner stated that the Veteran's GERD is a condition with a clear and specific etiology and diagnosis. The examiner further stated that the Veteran does not have proven reflux and that the Veteran’s diagnosis was initially presumptive based on his clinical symptoms of heartburn but GERD and heartburn are not synonymous. The examiner explained that heartburn is a common symptom of reflux but that reflux can occur without heartburn and heartburn can occur without reflux. The examiner noted that the Veteran complained of reflux in December 2015 but he has not been evaluated by scope or by X-ray for reflux. The examiner further explained that obese people are almost three times as likely than "normal people" to have reflux. The examiner also noted that the Veteran’s alcohol consumption is another factor in symptoms of heartburn, that Veteran's body weight is his most significant risk for GERD and that the Veteran’s weight is the most likely cause of his heartburn symptoms. The examiner further opined that because the Veteran’s complaints of heartburn arose in 2013, three years after separation and six years after duty in the Persian Gulf, it is less likely that any putative GERD is due to a theoretical exposure to an environmental hazard. The Board notes that the pertinent evidence added to the record since the final denial in June 2012 and includes a medical statement from N.S., PA-C, dated in January 2021, who opined that the Veteran's severe alcohol abuse disorder is at least likely as not the cause or at minimum an exacerbating factor of his GERD. This evidence was not previously of record and is not cumulative or duplicative of evidence before the RO in June 2012. Hence, the evidence is "new" within the meaning of 38 C.F.R. § 3.156. The evidence is relevant and probative of the issue regarding the development of GERD and bears directly and substantially upon the facts regarding whether the Veteran's GERD is related to an inservice event. Since the credibility of the evidence is presumed in determining whether new and material evidence has been submitted, this evidence is relevant and probative of the issue of whether the Veteran's GERD was incurred as a result of active service. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the standards under 3.156(a) have been met and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. Entitlement to service connection for GERD, including as secondary to the adjustment disorder with anxiety, depressed mood, and alcohol use disorder The Veteran maintains that he developed GERD as a result of his alcohol use associated with his service-connected adjustment disorder. The Veteran has been awarded service connection for an adjustment disorder with anxiety, depressed mood and alcohol use disorder and the record reveals that he has a current diagnosis of GERD. Based on a thorough review of the record, the Board finds that the evidence is in relative equipoise as to whether the Veteran has GERD secondary to his psychiatric disorder, diagnosed as adjustment disorder with anxiety and alcohol use disorder. In this regard, the Board notes that there is conflicting evidence concerning the relationship between the currently diagnosed GERD and his service-connected adjustment disorder with mixed anxiety and alcohol and substance abuse. Following a VA examination in March 2016, the examiner stated that it is less likely that any putative GERD is due to theoretical exposure to an environmental hazard. Subsequently, in January 2019, a VA examiner opined that the condition claimed is less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner explained that GERD is the result of a structural defect and is not caused by exposure to alcohol or drug abuse. On the contrary, submitted in support of the Veteran’s claim was an etiology opinion from N.S., PA-C, dated in January 2021. The provider opined that the Veteran’s severe alcohol abuse disorder is at least as likely as not the cause or at minimum an exacerbating factor of the Veteran’s GERD. The provider noted that a medical journal explained that alcohol consumption probably precipitates GERD and that the exposure of the esophagus and stomach to alcohol may cause direct damage to esophageal and gastric mucosae. The provider further noted that toxic acetaldehyde metalized from alcohol could affect the function of the esophagus and stomach and that dysfunction of the LES and esophageal peristalsis and abnormal gastric acid secretion maybe involved in the pathogenesis of alcohol-related GERD. The Board finds that when resolving reasonable doubt in the Veteran's favor, the evidence is at least in equipoise as to whether his current GERD is secondary to his service-connected adjustment disorder with mixed anxiety and depressed mood, alcohol abuse and substance abuse. The Board finds that the medical opinions discussed above are of relatively equal weight. As such, the Board finds that the evidence is at least in equipoise as to whether the Veteran's GERD is secondary to his adjustment disorder with mixed anxiety and depressed mood, alcohol abuse and substance abuse. The Board notes that it is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, 17 Vet. App. 305 (2003). Accordingly, the Board finds that the positive and negative evidence of record is at least in relative equipoise and that the benefit of the doubt rule applies. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for GERD as secondary to adjustment disorder with mixed anxiety and depressed mood, alcohol abuse and substance abuse, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Entitlement to service connection for obstructive sleep apnea, to include as secondary to GERD or as secondary to the service-connected adjustment disorder with anxiety disorder and alcohol use disorder The Veteran essentially contends that he currently suffers from obstructive sleep apnea that had its onset in service. Alternatively, the Veteran maintains that his obstructive sleep apnea developed as a result of his GERD. As an initial matter, the record clearly reflects that the Veteran has a diagnosis of obstructive sleep apnea. Significantly, the record contains a February 2013 sleep study which reported a finding of mild obstructive sleep apnea syndrome. The Veteran also submitted a private medical statement, dated in February 2021, which reported a diagnosis of obstructive sleep apnea. In addition, as noted above, service connection has been established for GERD and the Veteran is also service connected for adjustment disorder with anxiety disorder and alcohol and substance use disorder. In August 2018, a VA examiner opined that the claimed obstructive sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran has reported poor and interrupted sleep; however, night sweats and increased sleep latency due to over thinking are not typical symptoms of sleep apnea. Furthermore, the examiner noted that there does not seem to be a definite indication that impaired sleep due to sleep apnea occurred during the Veteran’s service. Therefore, the examiner concluded that the diagnosis of sleep apnea is less likely than not incurred in or caused by difficulty sleeping during service. An opinion as to secondary service connection was not provided. In contrast, the Veteran submitted a private etiology opinion from N.S., a PA-C, dated in January 2021. The provider concluded that that the Veteran’s obstructive sleep apnea is at least as likely as not secondary to the Veteran's alcohol use disorder. The provider based the conclusion on medical studies reflecting a positive medical link between alcohol consumption and obstructive sleep apnea. The examiner noted that the European Respiratory Journal published an article titled “Effect of Moderate Alcohol Upon Obstructive Sleep Apnea,” that this article states that modest alcohol consumption, giving a mean blood alcohol concentration of 0.07gx dL (-1), significantly increases both obstructive sleep apnea frequency and mean sleep cardiac frequency. The provider indicated that the Veteran is noted to have severe alcohol abuse disorder which would even further exacerbate/cause his obstructive sleep apnea. The provider stated that, taking these and numerous other sources into consideration, it was his opinion that the Veteran’s severe alcohol abuse disorder is at least as likely as not the cause or at minimum an exacerbating factor of his obstructive sleep apnea. The Board finds that when resolving reasonable doubt in the Veteran's favor, the evidence is at least in equipoise as to whether his obstructive sleep apnea is secondary to his service-connected adjustment disorder with anxiety disorder and alcohol use disorder. The private provider appears to have reviewed relevant medical literature and provided etiological opinion supported by rationale. There is no contrary opinion of record addressing secondary service connection. The Board notes that it is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, supra. Accordingly, the Board finds that the positive and negative evidence of record is at least in relative equipoise and that the benefit of the doubt rule applies. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for obstructive sleep apnea is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 4. Entitlement to a rating in excess of 30 percent for adjustment disorder with mixed anxiety and depressed mood, and alcohol use disorder, prior to July 10, 2016 and in excess of 50 percent thereafter The Veteran contends that his adjustment disorder is more severe than reflected by the ratings currently assigned. The Veteran’s adjustment disorder was previously rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9440; he is not rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9413. His disability is rated as 30 percent disabling prior to July 10, 2016, and as 50 percent disabling thereafter. Psychiatric disabilities are evaluated under the General Rating Formula for Mental Disorders. A 30 percent rating is warranted for a mental disorder when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. The rating agency shall also consider the extent of social impairment, but not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Id. at 118. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. A rating action in August 2010 granted service connection for adjustment disorder with mixed anxiety and depressed mood, alcohol and substance abuse in early remission and assigned a 10 percent rating. The Veteran’s claim for an increased rating was received in June 2015. In conjunction with his claim, the Veteran was afforded a VA examination in July 2015. The Veteran indicated that he was engaged in 2010 but terminated the relationship in 2011, that he had one daughter from this relationship with whom he had a great relationship, that he had a pretty good relationship with his parents and brother, and that he had positive social relationships. The Veteran reported that he currently worked for the postal service and he denied any work-related difficulty. The Veteran indicated that he was currently receiving individual therapy for his psychiatric disorder and also reported outpatient substance abuse treatment in 2013. The examiner noted that symptoms of the Veteran’s condition included depressed mood and chronic sleep impairment. On examination, the examiner noted that the Veteran was oriented to person, place, time, and purpose. Eye contact was found to be appropriate, psychomotor activity was found to be normoactive, mood was assessed to be dysphoric with constricted affect, attention and concentration were found to be good and speech was found to be unremarkable in regard to rhythm, rate, volume, and amount. Thought processes were found to be logical and goal directed and thought content was found to be significant for guilt and substance use/recovery concerns. There was no obvious impairment in memory was noted and the Veteran denied current suicidal ideation and/or intent. The examiner noted that there was no homicidal ideation and that no hallucinations or delusions were reported or evidenced during the examination. Insight was assessed to be fair and judgment was assessed to be appropriate. Veteran remained cooperative throughout the interview. The pertinent diagnoses were adjustment disorder with mixed anxiety and depressed mood, and severe alcohol use disorder. The examiner noted that the Veteran’s adjustment disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Treatment records dated from March 2016 to July 2016 show that the Veteran received ongoing clinical attention for his psychiatric disorder, which include group therapy. Among these records is the report of an evaluation from Dr. J.A., dated in June 2016, following which it was noted that the Veteran meets the criteria for PTSD that would include his current adjustment disorder diagnosis; the examiner further noted that the Veteran also continued to meet the criteria for alcohol dependence secondary to PTSD. He described the severity of the Veteran’s psychiatric disorder as moderate. Submitted in support of the Veteran’s claim was the report of a private DBQ examination for PTSD conducted in July 2016. It was noted that the Veteran was divorced and lived with his daughter, that he works full time at the post office and that he continues to need alcohol dependency. The examiner noted that the Veteran’s condition was manifested by symptoms that include depressed mood, anxiety, chronic sleep impairment, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. The pertinent diagnosis was PTSD to include as secondary to alcohol dependence, depression, and anxiety. The examiner noted that the Veteran’s adjustment disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was afforded a more recent DBQ examination in September 2020, at which time he indicted that he has been married since March 2018. The reported that he has a daughter from a previous union who currently lives with him, as well as his wife’s two children from a previous marriage. The Veteran indicated that he recently quit his job at FedEx. The Veteran indicated that he gets angry about everything, always in a stale mood and he’s never happy. He does not binge drink anymore than once or twice a year when he goes out with his wife. The examiner noted that the Veteran’s condition was manifested by symptoms that include anxiety, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. The examiner noted that the Veteran presented with normal mood and affect, that his thoughts were linear and logical, that he was oriented times three and that his speech was normal in rate and volume. The Veteran was reported to be casually dressed with fair to good hygiene. The examiner indicated that the new diagnosis was other specified personality disorder with continued use of alcohol and cannabis. The examiner explained that the inflexibility of his personality caused distress in many areas of his life and continued basically unabated based on self-report in today's interview. The examiner noted symptoms of irritability and anxiety in response to minor daily stress (e.g., "always in a stale mind, never happy). The examiner stated that the Veteran’s other specified personality disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. During the December 2020 hearing, the Veteran testified that he had taken a break from work over the past summer, that he required that break for his mental health and that he had used his annual leave to cover that break. He testified that he was a letter carrier, that he works independently outside most of the time, that his family walks on eggshells to avoid setting him off and that gets upset for no reason and in an predictable fashion. He testified that he had a few close friends that are veterans and that got together socially on rare occasions. He also testified that he had worked in an acting supervisory role at his place of employment, that he has good days and bad days, and that he had been married for about three years. For the period prior to July 10, 2016, the Board finds that the Veteran’s adjustment disorder not manifest occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, occupational and social impairment with reduced reliability and productivity. The record reflects the Veteran’s complaints of a depressed mood, anxiety, and chronic sleep impairment; he also reported problems with loss of meaning and some issues with guilt. During the June 2015 VA examination, the Veteran indicated that he was currently working for the United States Postal Service and he denied any work-related difficulty. He also reported a pretty good relationship with his parents and brother, and positive social relationships The Veteran's functional impairments were characterized as moderate by his health care providers. In fact, in a medical statement from the Veteran’s private psychologist, dated in June 2016, the examiner described the level of the Veteran's psychiatric disorder as moderate. The Veteran did not allege, and the record did not establish, a flatten affect, speech that was circumstantial, circumlocutory or stereotyped, panic attacks, difficulty in understanding complex commands; impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood or difficulty in establishing and maintaining effective work and social relationships. Moreover, occupational and social impairment with deficiencies in most areas were not shown for the appeal period prior to July 10, 2016. The Veteran has reported a depressed mood and anxiety; therefore, impairment to mood was demonstrated. The Veteran reported that he had a great relationship with his daughter, a pretty good relationship with his parents and brother, that he had positive social relationships and that he did not have any work-related difficulty that in a June 2015 VA examination report. Therefore, impairment to work and family relations was not shown. A June 2015 VA examiner found the Veteran’s thought processes to be logical and goal-directed and that there were no hallucinations or delusions. Judgment was not impaired as it was consistently found to be intact or good during this appeal period and thinking was not found to be impaired. School was not attempted during the appeal period. The record does not establish, and the Veteran has not alleged, suicidal ideation, obsessional rituals which interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships. Therefore, occupational and social impairment with deficiencies in most areas was not shown for the appeal period prior to July 10, 2016. For the appeal period beginning on July 10, 2016, the Veteran’s adjustment disorder did not manifest as occupational and social impairment with deficiencies in most areas. Impairment to mood was demonstrated as the Veteran reported depression and anxiety. Some impairment to work was demonstrated as the Veteran reported that he stepped down from an acting supervisory role and that he had to take several weeks of leave last summer due to his mental health impairments. Impairment to family relations was not demonstrated as the Veteran was married during this appeal period and he maintained a relationship with his daughter and his step-children. Judgment was not impaired as it was consistently found to be intact or good during this appeal period and thinking was not found to be impaired. School was not attempted during the appeal period. Difficulty in adapting to stressful circumstances was shown during the appeal period as the Veteran was unable to continue in the acting supervisor role at this place of employment. However, the Veteran was able to continue in his letter carrier role. The record does not establish, and the Veteran has not alleged, suicidal ideation, obsessional rituals which interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, and an inability to establish and maintain effective relationships. Therefore, occupational and social impairment with deficiencies in most areas was not shown for the appeal period beginning on July 10, 2016. Total social and occupational impairment was not shown at any time during the appeal period. The Veteran remained employed throughout the appeal period. He als married his current wife and maintained a relationship with his daughter. The Veteran has not displayed gross impairment in thought processes or communication, nor has the record shown that he is a persistent danger of hurting himself or others or grossly inappropriate behavior. Moreover, there is no evidence that the Veteran has experienced hallucinations or delusions, or obsessive rituals. Further, the Veteran has not displayed disorientation to time or place, or memory loss for names of close relatives, his prior occupations, or his own name. Additionally, there is no evidence or allegation that he was unable to maintain minimal personal hygiene. Mental status examinations during the appeal period consistently found the Veteran's grooming and hygiene to be appropriate, adequate or good. There is no evidence or allegation that the Veteran's psychiatric symptoms manifested in interference or difficulties resulted in the inability to perform activities of daily life, to include maintenance of minimal hygiene. Moreover, this is not a disability picture indicating total occupational and social impairment at any time during the appeal period. In determining that the criteria for a higher rating for the Veteran's service-connected adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder are not met, the Board has considered the applicable rating criteria not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether additional staged ratings under Hart, supra is appropriate; however, the Board finds that his symptomatology was been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. The Veteran nor his representative have not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Additionally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, the Veteran has reported being employed throughout the period on appeal. Therefore, a TDIU has not been raised. In conclusion, the Board, however, finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent prior to July 10, 2016, and in excess of 50 percent thereafter. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for patellofemoral syndrome, right knee is remanded. The Veteran contends that his right knee patellofemoral syndrome is more severely disabling than reflected in the currently assigned rating. At his personal hearing in December 2020, the Veteran testified that his right knee patellofemoral syndrome had worsened since his last examination. Specifically, the Veteran reported that he experiences instability in the right knee as well as painful motion. The Veteran said that he noticed a lot of instability especially with going up or down stairs. The Veteran indicated that the right knee usually feels like its about to give out; he noted that he had trouble using stairs. The Veteran also reported having some swelling in the right knee. The Veteran most recently underwent a VA examination to assess his service-connected right knee patellofemoral pain syndrome in June 2019. The June 2019 VA examination report reflects a range of motion of zero degrees to 130 degrees in the right knee; no pain was noted on examination. No joint instability was noted. However, as noted above, at his December 2020 Board hearing, the Veteran stated he has reduced range of motion and instability in his right knee. Given the evidence of worsening of the Veteran's right knee disability since the June 2019 VA examination and the need for more current findings necessary to rate his right knee disability, a new examination is needed. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, ensure that the Veteran is scheduled for an examination by an appropriate clinician to determine the current severity of his service-connected right knee patellofemoral syndrome. The examiner must review pertinent documents in the Veteran's electronic claims file in conjunction with the examination. All indicated studies should be conducted, and all findings reported in detail. The examiner must: (A) Report the Veteran’s ranges of motion of the right knee in degrees, in passive motion, active motion, and in weight-bearing and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she must clearly explain why that is so. (B) Determine the extent the right knee disability is manifested by weakened movement, excess fatigability, incoordination, or pain due to flare-ups. This determination should be made in terms of the degree of additional range-of-motion loss. The examiner must ask the Veteran if he has current flare-ups. (C) The examiner should indicate whether there is any lateral instability and/or recurrent subluxation. If instability is present, the examiner should, based on the examination results and the Veteran's documented medical history and assertions, assess whether such instability is slight, moderate, or severe. The VA examiner should not only assess the degree of any knee instability found on examination, but should also elicit from the Veteran a complete description of the instability experienced in daily life; thereafter, the VA examiner should provide an opinion as to whether such reported instability is consistent with the objective manifestations of such found on examination, and provide a rationale for any distinction in the objective assessment from the reported subjective symptoms. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Suzie S. Gaston, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.